Ian Winson

Arthroscopic treatment of osteochondral lesions of the talus

We reviewed, retrospectively, 65 patients who had undergone arthroscopic treatment for osteochondral lesions of the talus. The 46 men and 19 women with a mean age at operation of 34.25 years, were followed up for a mean of 3.5 years. The medial aspect was affected in 45 patients and the lateral aspect in 20. All the lateral lesions and 35 (75%) of the medial lesions were traumatic in origin. Medial lesions presented later than lateral lesions (3 v 1.5 years) and had a much greater incidence of cystic change (46% v 8%). At follow-up, 34 patients had achieved a good result, and 17 and 14 fair and poor results, respectively. Of the 14 poor results, 13 involved medial lesions. Cystic lesions had a poor outcome in 53% of patients. Excision and curettage led to better results than excision and drilling of the base. Further arthroscopic surgery for patients with a poor result was disappointing. There was no association between outcome and the patients age.

Osteochondral Lesions of the Talus: A Revised Classification

Osteochondral lesions of the talus present a numerically small but therapeutically significant problem to the foot surgeon. The diagnosis and investigation of such lesions have been greatly enhanced by modern high resolution magnetic resonance imaging capabilities, which have provided far greater detail of the pathological anatomy. We have reviewed our experience in this area and suggest a revised classification for osteochondral lesions appropriate to the detail available on magnetic resonance imaging scans. The cause of osteochondral lesions is also discussed.

Arthroscopic ankle arthrodesis

We reviewed 116 patients who underwent 118 arthroscopic ankle arthrodeses. The mean age at operation was 57 years, 2 months (20 to 86 years). The indication for operation was post-traumatic osteoarthritis in 67, primary osteoarthritis in 36, inflammatory arthropathy in 13 and avascular necrosis in two. The mean follow-up was 65 months (18 to 144). Nine patients (10 ankles) died before final review and three were lost to follow-up, leaving 104 patients (105 ankles) who were assessed by a standard telephone interview. The preoperative talocrural deformity was between 22 degrees valgus and 28 degrees varus, 94 cases were within 10 degrees varus/valgus. The mean time to union was 12 weeks (6 to 20). Nonunion occurred in nine cases (7.6%). Other complications included 22 cases requiring removal of a screw for prominence, three superficial infections, two deep vein thromboses/pulmonary emboli, one revision of fixation, one stress fracture and one deep infection. Six patients had a subtalar fusion at a mean of 48 months after ankle fusion. There were 48 patients with excellent, 35 with good, 10 with fair and 11 with poor clinical results.

Ankle arthrodesis and its relationship to ipsilateral arthritis of the hind- and mid-foot

It has been suggested that arthrodesis of the ankle leads to osteoarthritis of the joints of the ipsilateral hind- and midfoot. We believe these studies overlooked the presence of osteoarthritic changes in these joints before the arthrodesis. We reviewed the pre-operative radiographs of 70 patients with osteoarthritis of the ankle who underwent 71 ankle arthrodeses (one was bilateral). The talonavicular, calcaneocuboid, subtalar and naviculocuneiform joints were given an osteoarthritis score according to Kellgren and Lawrence. The mean age at operation was 54.9 years and the most common indication was for post-traumatic osteoarthritis (52 cases). A total of 68 patients showed pre-existing arthritis in either the hind- or mid-foot, with the subtalar joint the most commonly affected. Ipsilateral hind- and mid-foot arthritis is almost universally present in patients with arthritis of the ankle requiring arthrodesis. The presence of such changes may not be a consequence of this arthrodesis.

The role of Plantaris Longus in Achilles tendinopathy: a biomechanical study.

BACKGROUND The Plantaris Longus Tendon (PLT) may be implicated in Achilles (AT) tendinopathy. Different mechanical characteristics may be the cause. This study is designed to measure these. METHODS Six PLT and six AT were harvested from frozen cadavers (aged 65-88). Samples were stretched to failure using a Minimat 2000™ (Rheometric Scientific Inc.). Force and elongation were recorded. Calculated tangent stiffness, failure stress and strain were obtained. Averaged mechanical properties were compared using paired, one-tailed t-tests. RESULTS Mean stiffness was higher (p<0.001) in the PLT, measuring 5.71 N/mm (4.68-6.64), compared with 1.73 N/mm (1.40-2.22) in AT. Failure stress was also higher (p<0.01) in PLT: 1.42 N/mm(2) (0.86-2.23) AT: 0.20 N/mm(2) (0.16-0.25). Failure strain was less (p<0.05) in PLT: 14.1% (11.5-16.8) than AT: 21.8% (14.9-37.9). CONCLUSIONS The PLT is stiffer, stronger than AT, demonstrating potential for relative movement under load. The stiffer PLT could tether AT and initiate an inflammatory response.

Calcaneal spurs and plantar fasciitis

Abstract To design a measuring and grading system for calcaneal spurs and determine the incidence and dimensions of calcaneal spurs in plantar fasciitis, hindfoot lateral radiographs were studied, comparing patients who had a consultant diagnosis of plantar fasciitis with controls, matched for age, sex, side and total calcaneal length. Observers graded calcaneal spurs into four groups; (absent to severe), and perpendicular radiographic dimensions were later measured. Plantar fasciitis patients in our group were commonly female, over 30 years. On radiographs of the plantar fasciitis group, 60% of spurs were graded as moderate or severe compared with 2.5% of controls. Spurs over 1 mm long in the longitudinal axis of the calcaneum were present in 25 of 37 cases with fasciitis, and 2 of 40 controls. The observational 4-point grading system correlated with measured spur length. There is a strong correlation with calcaneal spurs over 1 mm long and plantar fasciitis, which may be easily observed radiographically.

Arthroscopic resection of talocalcaneal coalitions--a bicentre case series of a new technique.

BACKGROUND Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. We describe an arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet). METHODS Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 to 5.5 years. RESULTS Pain and SAFAS improved in 7 patients. Subtalar movements were improved in all feet. All patients achieved early good function but one relapsed requiring subsequent fusions. One posterior tibial nerve was damaged. CONCLUSIONS Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. Patient selection and preoperative planning are crucial to avoid relapse and complication. This series from two independent surgeons supports the feasibility and effectiveness of this technique.

Foot orthoses: an audit of expenditure and efficacy

Abstract Foot orthoses cost the National Health Service £12 million per year in the UK. In this study, foot orthoses consumed 75% of the appliances budget of a district general hospital. Prices of orthoses showed wide variation between items and for the same item. Results of a postal questionnaire showed 97% of patients thought the appliances staff were satisfactory or excellent, 48% used their appliance continually, but 11% never used them. 43% had a satisfactory orthosis which they used regularly after a single visit to the clinic. Use of the appliance brought improvement for 48% of patients. In this study customized insoles have not shown improved outcomes over ‘off-the-shelf’ types. We believe that detailed controlled trials of benefit to the patient are necessary to justify the increased cost of modern dynamic insoles. Unsatisfactory elements of the orthotics service may be resolved by improving management of the service and controlled scientific assessment.

Arthroscopic triple fusion joint preparation using two lateral portals: A cadaveric study to evaluate efficacy and safety

BACKGROUND Arthroscopic triple fusion has several advantages over open techniques, but its use has yet to become widespread. Preliminary published techniques use five portals with neurovascular risk. Our aim was to assess the safety and efficacy of an alternative lateral two portal technique. METHODS Four cadaveric hindfeet were arthroscopically prepared for a triple fusion using two lateral portals. The distance to relevant subcutaneous nerves was measured as well as the prepared joint surface percentage. RESULTS Mean distance from mid-lateral portal to the nearest sural nerve branch was 22.3mm (range 20-24mm) and from the dorsolateral portal to the intermediate branch of the superficial peroneal nerve was 7.8mm (range 4-11mm). Mean percentages of joint preparation were 63% (talar head), 62% (navicular), 75% (calcaneum) and 74% (cuboid). CONCLUSIONS Two lateral arthroscopic portals allow adequate joint preparation for triple fusion procedures. The proximity of subcutaneous nerves is important to appreciate when using these portals.

The pattern of motion of the longitudinal arch of the foot

Abstract We studied motion of the longitudinal arch of the foot using roentgen stereophotogrammetric analysis. Motion was analysed in response to great toe dorsiflexion, maximum plantarflexion/supination and heel raise, all actions previously stated to alter the height of the longitudinal arch. The largest amounts of motion were seen in the talonavicular joint (ranging from 37.1° to 14.2°) This included significant amounts of plantarflexion, adduction (or internal rotation) and supination occuring during the process of arch raising. This pattern of motion was seen in all forms of arch raising activity studied. Forced great toe dorsiflexion induced the maximum motion seen in the talonavicular joint. Motion of a significant degree was also induced in the talocalcaneal joint (17.9-8.6). Anterior to this motion was less (10.1 - 3.5° for the total motion in the naviculo-cuneiform joint and 8.0-3.0° for the cuneiform-metatarsal joint) and in the longtudinal plane these joints went into pronation. From a clinical point of view, it is important to recognize the role of the talonavicular joint in arch motion and that the involvement of the talonavicular joint in this sort of activity occurs in all three planes.